Benchmarking Inpatient Antimicrobial Use: A Comparison of Risk-Adjusted Observed-to-Expected Ratios.

Background: Increasing antibiotic resistance has made benchmarking appropriate inpatient antibiotic use a worldwide priority supported by expert societies and regulatory bodies; however, standard risk adjustment for fair interfacility comparison has been elusive. We describe a risk-adjusted antibiotic exposure ratio that may help facilitate assessment of antimicrobial use. Methods: This was a retrospective cohort study of 2.7 million admissions evaluating a wide array of potential explanatory variables for correlation with expected antibiotic consumption in a 2-step approach using recursive partitioning and Poisson regression. Observed-to-expected ratios of risk-adjusted antibiotic use were calculated. Three models of varying complexity were compared: (1) a complex ratio consisting of all available antibiotic use risk factors in a hierarchical model; (2) a simplified antimicrobial stewardship program (ASP) ratio using common facility and encounter factors in a single-level model; and (3) a facility ratio using only broad hospital characteristics. Results: Diagnosis-related groups, infection present on admission, patient class, and unit type were the major predictors of expected antibiotic use. Aside from a history of gram-positive resistance in the prior 12 months for anti-methicillin-resistant Staphylococcus aureus drugs, additional clinical and comorbid history information did not improve the model. The simplified ASP ratio demonstrated higher Pearson correlation (R2 = 0.97-0.99) to the complex ratio than the facility ratio (R2 = 0.57-0.85) and provided clinical explanations when discordant. Conclusions: The simplified ASP ratio is derived from a parsimonious model that incorporates disease burden through patient-level risk adjustment and better informs stewardship assessment. This may allow for improved comparison of antibiotic use between healthcare facilities.

Telehealth insights from an integrated care system.

The COVID-19 pandemic accelerated telehealth expansion trends as policy makers instituted flexibilities and coverage changes. Federal telehealth flexibilities expire, however, at the end of 2024. To decide whether to extend those flexibilities, policy makers need information about consumer telehealth preferences, impacts of telehealth on care usage and quality, and telehealth accessibility for the full diversity of patients. Research from one of the nation's largest integrated, value-based health systems provides insights. Findings suggest that telehealth utilization has dropped since the peak of the pandemic but remains higher than prepandemic levels. Telehealth appears to be replacing in-person visits rather than leading to more total visits. Patients generally prefer in-person care but many like having the option to use video- and phone-based telehealth, and both video- and phone-based care appear to be helping patients access primary care. An integrated, value-based care approach may assist a diverse range of patients in accessing telehealth services. Action is still needed, however, to ensure that the full diversity of patients can easily access telehealth offerings. Based on experiences within our health system, we recommend that policy makers maintain public and private payer coverage for video- and phone-based telehealth services; encourage well-designed value-based payment models to simplify and expand telehealth access; improve broadband accessibility and broadband and device affordability so that all patients can access telehealth services; and hold digital health to equivalent high standards for care quality, safety, patient satisfaction, clinical outcomes, and health equity as in-person care.